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> COTTER CORPORATION SAMPLE SUBMITTAL AND TRACKING FORM <br />Sample Submittal sib <br />C: P.O. Box 1750 3: P.O. Box 1750 <br />Callon City, CO 81215 Caiion City, CO 81215 <br />Sample Loc./ID No. _ <br />Sample Date . f 1Yme `~ <br />1 Y <br />Collected By <br />Field Custodian Z—i nt '- <br />Delivered By <br />Received By <br />Date Recd. <br />Time Recd. <br />l.UiICC <br />via -o.ac a,so.auw.,.... <br />L <br />Lab. No.(s) <br />Date Data Entered <br />N: P.O. Box 700 <br />Nucla, CO 81424 <br />Data Entry By <br />Laboratory Desti ation if not Cotters <br />f <br />s• <br />/0 > d- <br />1. Sample 1)rpe: Air Water Soil/ Other (specify): <br />2. Analysis - Test series requested: eye ` <br />3. Field Data - Preservation: �''�• `'�� •"� �'`- ' <br />4. <br />S. <br />Date analysis required by (if not Holding Time): _ <br />Special handling conditions or other instructions: <br />6. Invalidating circumstances? If YES initial { <br />COMMENTS - Explanation of noted items: <br />) and explain below. <br />( ) Check if additional attachments. <br />QA Review: <br />Sample valid? YES ( <br />QAC <br />) NO ( ) If NO, explain: <br />Date <br />3 - - Pam 4d of 47 <br />